The impact of a nurse-led clinic on self-care ability, disease-specific knowledge, and home dialysis modality.
Several studies on the impact of early education for patients with CKD show positive effects, such as delayed initiation of renal replacement therapy (RRT) (Devins, Mendelssohn, Barre, & Binik, 2003), increasing proportion of permanent vascular access (Lindberg et al., 2005), more patients intending to and starting dialysis with a serf-care modality (Goovaerts, Jadoul, & Goffin, 2005; Manns et al., 2005), and extended survival (Devins, Mendelssohn, Barre, & Binik, 2005). Therefore, care goals are to support patients in handling their health-related situations and to empower patients to achieve a higher level of disease-related knowledge, capability, autonomy, and self-efficacy, as well as have better control of their life situations. In summary, it is a question of supporting and increasing patient involvement and self-care ability. Involvement means understanding and having knowledge about one's health-related situation, and being able to take part in plans and decisions concerning one's own care. In this context, self-care can be described as the activities required for an optimal daily life with a disease. Self-care ability can be briefly described as knowledge, competence, and activities related to health (Orem, 1985).
The specific components of self-care applicable to people with Stage 4 and Stage ,5 CKD (such as those with glomerular filtration rate [GFR] less than 30 ml/min) are having control over nutritional and fluid intake, physical activity, and weight, as well as monitoring bodily signs and symptoms (such as shortness of breath, edema, nausea, pruritus, dizziness, and signs of infection). It may involve tasks including maintaining a diet, blood pressure measurements, managing medication, dialysis access care, and in cases of diabetes, maintaining good metabolic control. When renal care is commenced at an early stage of CKD, the rate of reduction of renal function is slowed, and the need for the onset of RRT is delayed (Nahas & Belle, 2005; Ruggenenti, Schieppati, & Remuzzi, 2001), which is a significant gain, both from a patient and a public financial point of view. There is evidence showing that patients who are well controlled before the onset of dialysis do better when dialysis treatment is started (Jungers et al., 2001).
The overall goals in Sweden regarding the care of patients with advanced CKD--who can also be defined as high-risk patients--are to reduce progress of renal impairment; reduce complications of renal failure; reduce risk factors for later complications and mortality; prevent or alleviate uremic symptoms; prepare the patient, both physically and mentally, before dialysis or transplantation; and to offer good palliative care when RRT is not an option (Svensk Njurmedicinsk F6rening [SNK], 2007).
The prevalence of RRT in Sweden in 2005 was 815 per million inhabitants and the incidence was 125 per million inhabitants Glomerulonephritis is the most common ESRD-eausing disease among prevalent patients on RRT, and diabetes is the most common cause among incident patients. Among Swedish incident patients on dialysis, 72% started with hemodialysis (HD), and 28% started with peritoneal dialysis (PD) in 2005. Their mean age was 65 years. In Sweden, patients are usually referred to a nephrologist when the GFR is 40 to ,50 ml/min or below. Care in a renal outpatient clinic usually includes visits to a physician with patient educational measures managed by nurses (such as information on RRT options individually and "kidney schools"). However, it is becoming more common to have additional nurse-led clinics to complement the renal physician care.
The renal outpatient clinic at the Karolinska University Hospital/Solna has a pool of approximately 200 patients with GFRs of less than 20 ml/min. Patients usually see their physician at the clinic 3 to 4 times per year. The authors' clinic is striving for a high degree of self-care treatment. Patients are encouraged to choose self-care dialysis (such as PD, self-HD, or home HD) whenever appropriate, and to have a well-functioning, permanent dialysis access at least 3 months before initiation of dialysis.
Nurse-Led Clinics: Previous Experiences
From an international perspective, the nurse-led clinic concept as a specific service has developed since the 1990s. Previous studies have shown the following effects of nurse-led clinics: lifestyle changes; increased prevention; fewer hospital admissions; an improvement in quality of life, disease-related knowledge, and self-care and compliance; and reduced waiting times and costs (Grady et al., 2000; Griffiths et al., 2004; Loftus & Weston, 2001). It has also been shown that nurse-led prevention clinics are effective in achieving risk factor targets (for example, overweight, hypertension, serum lipids, smoking habits, and physical activity degree) (Denver, Barnard, Woolfson, & Earle, 2003; Mainie, Moore, Riddell, & Adgey, 2005; McHugh et al., 2001).
Despite previous efforts to prepare patients for RRT and inform them about dialysis options, the authors found that patients in the outpatient clinic experienced shortcomings related to information, conveyance of disease-related knowledge, and overall view of and involvement in care decisions (Picker Institute Europe, 2003). For people with chronic illnesses, these areas are important in terms of understanding their situations and coping with the self-care that is required.
The hypothesis of this study was that a nurse-led clinic, focusing on education and self-care, would be able to meet these reported shortcomings and further improve the opportunity for optimal care, and contribute toward increased involvement and self care skills in patients with advanced renal failure.
This study was part of a clinical practice development project. Two nurses were engaged in the study. They each had 15 to 20 years of professional experience in renal care. Their educational levels were RN, BSc in Nursing and RN, MSc in SocSc Caring Education. They also had additional post basic education in motivational and cognitive patient education. Alas, Sweden does not have any certification or special training in nephrology nursing.
During the study period of 12 months in 2004, 70 participants were recruited to the nurse-led clinic. The participants had CKD in Stages 4 and 5, were not yet on RRT, and were being seen regularly by a physician in the outpatient clinic. The majority of participants had a GFR of less than 20 ml/min (see Table 1). Participants were informed about the study verbally as well as in writing and enrolled on voluntary basis. They were referred consecutively by their physicians when the physicians decided there was a need for increased self-care support, psychosocial support and/or medical control (such as blood-tests, blood pressure, symptom monitoring, nutritional status, postoperative checkups.). At baseline, the participants' mean S/Creatinine was 410 [micro]mol/L and the mean estimated GFR was 13 ml/min (see Table 1).
The comparison group consisted of 153 patients with advanced renal failure, not yet on RRT, who had conventional care (see earlier description) without access to a nurse-led clinic in our unit during 2002 (see Table 1).
Patient visits occurred at varying intervals, depending on patients' needs and wishes, and on the rate of progression and symptoms of the renal failure. The goal was that the patient would see the nurse and the physician on every other visit, respectively. The nurse gave feedback to the physician. Each visit to the nurse-led clinic lasted approximately 60 minutes. The goal of the researchers was to use motivational interviewing (Lange & Tigges, 200,5; Miller & Rollnick, 2002; Shinitzky & Kub, 2001) using open-ended questions, maintaining an empathic attitude, avoiding argumentation, using active and reflective listening, and using timed exchange of information. The content of each visit was determined largely by each individual patient's questions and wishes. The focus was on discussions aimed at motivating, guiding, and supporting the patient; education (for example, about kidney function, symptoms and common health problems related to renal failure, test results, effects of medication, treatment alternatives); self-care (for example, diet, physical activity/exercise, medication, control of blood pressure and any occurring edema); daily life with a chronic illness; well-being and quality of life; and health check-up (uremic symptoms, blood pressure, dialysis access function, test results, nutritional status, and SGA). The Appraisal of Self-Care Agency (ASA) questionnaire and a study-specific questionnaire to assess disease-related knowledge were used on the second visit. Participants were also given education materials especially developed for this patient group in the form of a patient diary--"CKD Diary" (Melander, Pagels, Eriksson, Wang, & Magnusson, 2004). The diary provided an opportunity to read about different areas related to renal failure, and for the patients to make their own notes on health data, thoughts on health goals, behavioral changes, the disease, and one's own life situation. It was also used as a basis for discussion during the visit to the nurse clinic.
The ASA questionnaire (Gast et al., 1989) is based on Orem's Self-Care Theory (Orem, 1985). The instrument contains components which reflect motivation, as well as cognitive and cognative aspects of self-care ability and is composed of 24 questions. The responses reflect a subjective estimation of self-care ability, and scores range from 24 to 120. A higher score indicates a higher estimated self-care ability.
Inspired by the Toronto Informational Needs Questionnaire (Galloway et al., 1997), a study-specific questionnaire about disease-related knowledge and educational/informational needs (KEQ) was created. The aim of the questionnaire was to establish what information the patient regarded as important and what areas of knowledge needed to be improved. The questionnaire was content validated by a group of nephrology nurses and a patient group. It consisted of 15 questions, with response options of 1 to 5 in a Likert scale format. The higher the score, the more important the area of knowledge is graded.
Visits and Preparations for Further Treatment of Uremia
The numbers of visits per participant varied between 1 to 8 during the study period (mean = 2.8). Fifty-six patients (80%) had two or more visits. The interval between visits varied from 1 week to 7 months.
More than half of the participants (59%) who had chosen a mode of treatment chose self-care dialysis (see Table 2). In the authors' comparison group, 40% chose self-care dialysis (see Table 3).
Questionnaires on Self-Care Ability and Disease-Related Knowledge Needs
At the first visit, participants were asked to answer the ASA questionnaire, with a response rate of 74% of participants. At the second visit, the participants were asked to answer the KEQ questionnaire, with a response rate of 73%.
The perceived level of self-care ability, according to the ASA questionnaire, was between 61 to 120 points, out of a maximum score of 120. Those who had chosen HHD estimated their self-care ability to be higher (mean ASA score = 98), compared with the whole nurse-led clinic population (mean ASA score = 90). The group that chose HHD was also younger; their mean age was 54 years compared with the whole nurse-led clinic population, whose mean age was 67. Results from the KEQ questionnaire showed that self-care and effects of treatment options on family and everyday life were rated as the most important disease-related areas of knowledge (see Table 4).
Initiation of Dialysis
When dialysis was initiated, 11 (52%) of the participants started self-care dialysis, four started on HHD, and seven on PD. As shown in Table 2, of those who started dialysis (n = 21), 19 had a permanent and functioning dialysis access (AVF [n = 11], graft [n = 1], or PD catheter [n = 7]). Ten percent of the participants started dialysis with an emergency dialysis access. In the comparison group, 39% of the patients who were previously known in the unit started with an emergency dialysis access (see Table 3).
The CKD diary proved to be a very useful and appreciated tool for promoting self-care, disease-related knowledge, behavioral change and information, and staying in contact with relatives. The visits provided a good basis for health discussions about perceived quality of life, everyday situations, and health-promoting factors.
In summary, positive effects of the nurse-led clinic were evident, such as a greater proportion of participants choosing the self-care dialysis option, an increased proportion of functioning accesses at the initiation of dialysis, behavioral change (for example, in the form of increased physical activity), as well as increased control and prevention.
The major results of this study were that the participants in the nurse-led clinic both chose and started treatment in self-care alternatives to a greater extent than the patients in our historical comparison group (see Table 3). In the participant group, 52% of incident patients on dialysis started with self-care dialysis compared to 33% in the comparison group. Nationally, in Sweden, 72% of patients start dialysis with conventional HD and 28% with PD. Of the prevalent patients on HD, 3% have HHD (SRAU, 2006).
The fact that more patients chose self-care treatment can be seen as a result of improved disease-related knowledge and self-care ability, in combination with offers of and resources for PD and HHD. The result can be partly explained by the fact that the nurse and the patient often met during repeated visits, which made it possible to gradually build on the patient's disease-related knowledge and self-care ability. It is the authors' impression that a well-informed patient, who feels involved and receives the support and encouragement that he or she needs before initiation of RRT, tends to choose self-care treatment to a greater extent. In the authors' unit, self-HD (SHD) is also encouraged to a varying degree, depending on individual ability. As the level of SHD has usually not been formed to the individual at the initiation of dialysis, it has not been used as an effect measure in this study. That means that the proportions of patients who, to some degree, carry out self-care dialysis at the initiation of the treatment at the clinic are not visible in the authors' results. Also, the present results do not show what mode of treatment was considered by those participants who, at the end of the study, had not yet started dialysis. This will be very interesting to follow up.
The nurse holds a unique position in terms of providing education and support for the chronically ill (International Council of Nurses [ICN] 2000, 2006), in the complex care system. Providing patient education and supportive counseling places high demands on nurses, especially if the aim is to achieve a permanent change in behavior (Rankin, Stallings, & London, 2005; Redman, 2004, 2007). Optimal patient education is focused not only on disease and disease management, but takes into account the overall view, quality of life and everyday lifestyle (Rankin et al., 2005; Redman, 2004, 2007). This is highlighted by the results of the KEQ questionnaire.
The nurse-led clinic offered participants increased access to the care system, increased opportunities for information and follow-up, and increased opportunities for asking questions and discussions. It also provided a better basis for individualized learning than in the authors' earlier organization. The topics and issues that the patient wishes to discuss with the nurse during the visit often change in character as the patient approaches initiation of RRT. Then it is important that discussions and information about these topics are well timed. Attitude and communication technique are of great importance. We strived to encourage the patient's reflection about his or her disease, life situation, and role as a responsible cooperating partner. This can help the patient to make informed treatment decisions (ICN, 2003; UK Department of Health, 2002).
Another finding was that the visits provided a good basis for health discussions about perceived quality of life, everyday situations, and health-promoting factors.
The CKD diary as well as the ASA questionnaire might constitute an interesting practical tool when discussing perceived self-care ability and which mode of dialysis treatment would suit the individual. This needs to be further investigated.
The period preceding initiation of dialysis is often a stressful one (Harwood, Locking-Cusolito, & Spittal, 2005). It can be seen as a time before entering the unknown, which is how the individual would view dialysis treatment. Watnick, Kirvin, Mahnensmith, and Concato (2003) report that depressive symtoms are very common at intitiation of dialysis. A study by Klang, Bjorvell, and Clyne (1996) revealed that patients about to initiate RRT experienced a high level of anxiety. In order to make the transition as smooth as possible, it is important to prepare the patient both mentally and physically with a functioning dialysis access.
One result worth emphasizing is that nearly all participants (90%) who started dialysis had a functioning, permanent dialysis access (AVF, graft or PD catheter). This is better than the comparison group as well as earlier national statistics. In the comparison group, 61% of patients started HD with a permanent access (see Table 3). This can be compared to 75% in Europe and 54% in the USA, respectively (Pisoni et al., 2002). In the nurse-led clinic, the patient's dialysis access was checke,d and the self-care involved was discussed. On several occasions, problems concerning the dialysis accesses were noticed in the nurse-led clinic and could be dealt with in time before initiation of dialysis.
Medical events, such as aggravation of infection, initiation of dialysis using an emergency dialysis access due to a deficient fistula/graft, exacerbation of fluid overload and hypertension, incorrect use of drugs, and admissions to hospital, were prevented during the study period.
The preventive efforts could be exemplified by following case presentation. A 67-year-old man had undergone vascular access surgery in preparation for HD 1.5 years prior to the first visit to the nurse-led clinic, where physical examination revealed that the access had not developed correctly. This had not been noticed before either by the physician or the patient. Re-operation was carried out, and the access was checked at several follow-up visits in the nurse-led clinic. Five months after re-operation, HD was initiated with adequate access function.
Increased contact frequency and behavioral changes outcomes could be exemplified by the following case presentation. A 64-year-old woman with long-standing diabetes (adult) had gained 15 kg (33 pounds) in weight in 9 months due to inactivity and improper diet. Her body mass index (BMI) was 33. Despite medication, a raised blood pressure (BP) was also noted. The patient made five visits to the nurse-led clinic and was followed up by telephone. Using motivational interviewing that was focused on behavioral changes, a care plan was formulated with clear, achievable goals. The care plan described how the behavioral change would be achieved in practice. The CKD diary was used for support during this process. The behavioral changes included increased physical activity and 10 to 15 minutes walking with rest, which was increased to daily walks for 2 km (1.24 miles) without rest. The changes also involved a transition from irregular snacking to regular meals. After 6 months, the weight was stabilized, the BP had decreased from 160/95 to 130/80, and the patient experienced a subjective improvement of her breathing while walking. At the follow-up another 15 months later, the blood pressure was still at the lower level, and the patient had lost 8 kg (17.64 pounds) and reached a BMI of 30.
By using motivational interviewing as a communication technique, the nurse-led clinic is of importance in terms of changing behavior towards improved health. The nurse-led clinic has resulted in more frequent contact with the renal unit, which ensures increased medical control and increased opportunities for prevention. However, one has to take into account the inconvenience for the patients of too many frequent visits to the hospital, so it is important to coordinate these as much as possible. Telephone follow-up may be a complementing alternative.
Guiding and preparing--physically as well as mentally--patients with renal failure who are approaching initiation of RRT is a demanding task for the renal care team. With diminishing financial resources, nurses have to optimize various health care efforts for this category of patients. Combining the medical treatment with nurse-led clinics increases the prospect of a well-prepared patient at the initiation of RRT. Cooperation with the physician responsible for the patient is vital. For this type of service, it is important to clarify areas concerning liability and safety. In addition to adequate training and knowledge on the part of the nurse responsible for the patient, a clearly-defined medical responsibility, defined goals and tasks, and good follow up of the service are important safety factors.
One shortcoming of this study was that the comparison group was historical with retrospective data. Another shortcoming was the relatively small number of participants, which makes it more difficult to generalize and draw reliable conclusions. However, the authors' conclusions are in line with other controlled, randomized studies, in which the effects of nurse-led clinics on chronic disease have been evaluated (Denver et al., 2003; Griffiths et al., 2004; McHugh et al., 2001). Based on the results of this study, the unit made the authors' nurse-led clinic permanent.
Conclusions and Recommendations
Although caution should be taken drawing conclusions, the authors could see that for the participants, the nurse-led clinic led to improved opportunities for learning, self-care, discussions and reflections on their health situation, and the influence of the disease on everyday life. The nurse-led clinic has also provided an opportunity for increased medical control and prevention. A nurse-led clinic increased the opportunity to prepare the patients, both physically and mentally, for the initiation of dialysis.
For nephrology nurses involved in predialysis care, the nurse-led clinic may provide a challenge and an opportunity for professional development, and an opportunity to work more independently with education, structured communication, patient empowerment, behavioral change and prevention. For patients, the nurse-led clinic can result in improved outcomes.
Denver, E.A., Barnard, M., Woolfson, R.G., & Earle, K.A. (2003). Management of uncontrolled hypertension in a nurse-led clinic compared with conventional care for patients with type 2 diabetes. Diabetes Care, 26(8), 2256-2260.
Devins, G.M., Mendelssohn, D.C., Barre, P.E., & Binik, Y.M. (2003). Predialysis psycho educational intervention and coping styles influence time to dialysis in chronic kidney disease. American Journal of Kidney Disease, 42(4), 693-703.
Devins, G.M., Mendelssohn, D.C., Barre, EE., & Binik, Y.M. (2005). Predialysis psycho educational intervention extends survival in CKD: A 20-year follow-up. American Journal of Kidney Disease, 46(6), 1088-1098.
Galloway, S., Graydon, J., Harrison, D., Evans-Boyden, B., Palmer-Wickham, S., Burlein-Hall, S., et al. (1997). Informational needs of women with a recent diagnosis of breast cancer: Development and initial testing of a tool. Journal of Advanced Nursing, 25(6), 1175-1183.
Gast, H., Denyes, M., Campbell, J., Hartweg, D., Schott-Baer, D., & Isenberg, M. (1989). Self-care agency: Conceptualizations and operationalizations. Advances in Nursing Science, 12(1), 26-38.
Goovaerts, T., Jadoul, M., & Coffin, E. (2005). Influence of a pre-dialysis education programme (PDEP) on the mode of renal replacement therapy. Nephrology Dialysis Transplantation, 20, 1842-1847.
Grady, K., Dracup, K., Kennedy, G., Moser, D., Piano, M., Warner Stevenson, L., et al. (2000). Team management of patients with heart failure. A statement for healthcare professionals from the Cardiovascular Nursing Council of the American Heart Association. Circulation, 102, 2443-2456.
Griffiths, C., Foster, G., Barnes, N., Eldridge, S., Tate, H., Begum, S. et al. (2004.) Specialist nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area: The east London randomised controlled trial for high risk asthma (ELECTRA). British Medical Journal, 326(7432),144.
Harwood, L., Locking-Cusolito, H., & Spittal, J. (2005). Preparing for hemodialysis: Patient stressors and responses. Nephrology Nursing Journal, 32(3), 295-302.
International Council of Nurses (ICN). (2000). Nurses and primary health care (Position statement). Geneva, Switzerland: Author. Retrieved March 14, 2008 from http://www.icn.ch/ps primarycare.htm
International Council of Nurses (ICN). (2003). Position statement: Informed patients. Geneva, Switzerland: Author. Retrieved March 14, 2008 from, http://www.icn.ch/psinfopatients03. htm
International Council of Nurses (ICN). (2006). Position statement: Nursing care of the older person. Geneva, Switzerland: Author. Retrieved March 14, 2008 from, http://www. icn.ch/psolder.htm
Jungers, E, Massy, Z., Nguyen-Khoa, T., Choukroun, G., Robino, C., & Fakhouri, E (2001). Longer duration of predialysis nephrological care is associated with improved long-term survival of dialysis patients. Nephrology Dialysis Transplantation, 16(12), 2357-2364.
Klang, B., Bjorvell, H., & Clyne, N. (1996). Quality of life in predialytic uremic patients. Quality of Life Research, 5(1),109-116.
Lange, N., & Tigges, B. (2005). Influence positive change with motivational interviewing. The Nurse Practitioner, 30(3), 44-53.
Lindberg, J.S., Husserl, EE., Ross, J.L., Jackson, D., Scarlata, D., Nussbaum, J., et al. (2005). Impact of multidisciplinary, early education on vascular access placement. Nephrology News & Issues, 19(3), 35-36, 41-43.
Loftus, L., & Weston, V. (2001). The development of nurse-led clinics in cancer care. Journal of Clinical Nursing, 10, 215-220.
Manns, B.J., Taub, K., Vanderstraeten, C., Jones, H., Mills, C., Visser, M., et al. (2005). The impact of education on chronic kidney disease patients' plans to initiate dialysis with self-care dialysis: a randomized trial. Kidney International, 68(4), 1777-1783.
Mainie, P.M., Moore, G., Riddell, J.W., Adgey, J.A. (2005). To examine the effectiveness of a hospital-based nurse-led secondary prevention clinic. European Journal of Cardiovascular Nursing, 4, 308-313.
McHugh, F., Lindsay, G.M., Hanlon, R, Hutton, I., Brown, M.R., Morrison, C., et al. (2001). Nurse led shared care for patients on the waiting list for coronary artery bypass surgery: A randomised controlled trial. Heart, 86(3), 317-323.
Melander, S., Pagels, A., Eriksson, A., Wang, M., & Magnusson, A. (2004). Chronic kidney disease diary ("Dagbok far dig som hat njursvikt"). Patient diary Education material. Stockholm, Sweden. E Hoffmann-La Roche Ltd.
Miller, W., & Rollnick, S. (2002). Motivational interviewing: Preparing to change addictive behaviour (2nd ed.). New York: Guilford Press.
Nahas, M.E., & Bello A.K. (2005) Chronic kidney disease: The global challenge. Lancet, 365, 331-340.
National Kidney Foundation. (NKF). (2000). DOQI--Clinical practice guidelines for chronic disease. Part 6, guideline 12. New York: Author. Retrieved May 5, 2008, from, www.kidney.org/ professionals/doqi/kdoqi/p6_comp_ g12.htm
Orem, D. (1985). Nursing: Concepts of practice (3rd ed.). St Louis, MO: Mosby Year Book, Inc.
Picker Institute Europe. (2003). Through the eyes oft& patient (Questionnaire about the patient's experience of care quality [Frageformular om patientens upplevelse av vardkvalitet]. Stockholm, Sweden: Karolinska University Hospital, Department of Nephrology.
Pisoni, R.L., Young, E.W., Dykstra, D.M, Greenwood, R.N., Hecking, E., Gillespie, B., et al. (2002). Vascular access use in Europe and the United States: Results from the DOPPS. Kidney International, 61(1), 305-316.
Rankin, S., Stallings, K., & London, E (2005). Patient education in health and illness (5th ed.). Philadelphia: Lippincott Williams & Wilkins.
Redman, B. (2004). Advances inpatient education. New York: Springer Pub. Company.
Redman, B. (2007). The practice of patient education: A case study approach (10th ed.). St. Louis, MO: Mosby Elsevier.
Ruggenenti, E, Schieppati, A., & Remuzzi, G. (2001). Progression, remission, regression of chronic renal diseases. Lancet, 357, 1601-1608.
Shinitzky, H.E., & Kub, J.K. (2001) The Art of motivating behaviour change: The use of motivational interviewing to promote health. Public Health Nursing, 18(3), 178-185.
SRAU. (2006). Swedish registry of renal replacement therapy. RRT in Sweden 1991-2005 (Aktiv uremivard i Sverige 1991-2005). Stockholm, Sweden. Swedish Renal Registry. Retrieved May 5, 2008, from www.medscinet. net/snr/rapporter.aspx
Svensk Njurmedicinsk F6rening (SNF). (2007). Swedish renal care guidelines (2nd ed.) (Riktlinjer for omhandertagande av patienter med njursvikt). Stockholm, Sweden: Swedish Society of Renal Medicine. Retrieved May 5, 2008, from www.njur.se/Filer/ Kliniska_hjalpmedel/Riktlinjer_ure mi_2007.pdf
U.K. Department of Health. (2002). Chronic disease management and self-care: A practical aid to implementation in primary care. National Service Framework. London, United Kingdom, United Kingdom Department of Health.
Watnick, S., Kirvin, E, Mahnensmith, R., & Concato, J. (2003). The prevalence and treatment of depression among patients starting dialysis. American Journal of Kidney Disease, 41(1), 105-110.
Agneta A. Pagels, M.Soc.Sc. RN, is employed in the Department of Nephrology, Karolinska University Hospital, Stockholm, Sweden.
Marie Wang, RN, is a Staff Nurse, the Department of Nephrology, Karolinska University Hospital, Stockholm, Sweden.
Yvonne Wengstrom, OCN, PhD, is employed in the Department of Neurobiology, Care Science and Society, Division of Nursing, Karolinska Institute, Stockholm, Sweden.
Table 1 Participants in a Nurse-Led Clinic, Background Information Patients in Nurse-Led Clinic Comparison Group Patients, total number 70 153 Male 48 (69%) 100 (65%) Female 22 (31%) 53 (35%) Age (mean) 67 (Range 36-89) 65 (Range 19-88) Diabetes 22 (31%) 53 (35%) Glomerular filtration rate 13 (Range 5-30) 14 (Range 4-39) (GFR), ml/min. (mean) S/Creatinine, mmol/L(mean) 410 (Range 157-845) 384 (Range 130-953) Table 2 Choice and Initiation of Dialysis Mode in a Nurse-Led Clinic Number (n)/ Participants Who Had: Total Number (n) % Chosen a form of dialysis 61/70 187.1 Chosen self-care dialysis 36/61 59 Chosen conventional HD 22/61 36 Chosen to decline dialysis 3/61 4.9 Started dialysis 21/70 30 Started conventional HD 10/21 47.6 Started self-care dialysis 11/21 52.4 Started dialysis with permanent 19/21 90.4 dialysis access Table 3 Outcomes in Nurse-Led Clinic and Comparison Group Patients in Comparison Nurse-Led Group Outcomes Clinic (N = 70) (N = 153) Chosen self-care dialysis 59% 40% Started self-care dialysis 52% 33% Started dialysis with permanent 90% 61 dialysis access Started dialysis with emergency dialysis access 10% 39% Table 4 Disease-Related Knowledge and Educational/informational Needs Questionnaire (KEQ) Disease-Related Areas of Disease-Related Areas of Knowledge Knowledge Rated as Rated as Most Important to Learn Most Important More About "What happens if I refrain?" "The effects of the disease on relatives" "How can I continue my normal "Self-care" social and physical activities?" "What treatment suits me best "What treatment suits me best medically?" medically?" "How can I continue my normal "How should I take my medication?" social and physical activities?"
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|Author:||Pagels, Agneta A.; Wang, Marie; Wengstrom, Yvonne|
|Publication:||Nephrology Nursing Journal|
|Article Type:||Clinical report|
|Date:||May 1, 2008|
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